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Adult Non-Hodgkin Lymphoma Treatment (PDQ®)

Treatment Option Overview for Adult NHL

Treatment of non-Hodgkin lymphoma (NHL) depends on the histologic type and stage. Many of the improvements in survival have been made using clinical trials (experimental therapy) that have attempted to improve on the best available accepted therapy (conventional or standard therapy).

In asymptomatic patients with indolent forms of advanced NHL, treatment may be
deferred until the patient becomes symptomatic as the disease progresses. When
treatment is deferred, the clinical course of patients with indolent NHL
varies; frequent and careful observation is required so that effective
treatment can be initiated when the clinical course of the disease accelerates.
Some patients have a prolonged indolent course, but others have disease that
rapidly evolves into more aggressive types of NHL that require immediate
treatment.

Radiation techniques differ somewhat from those used in the treatment of
Hodgkin lymphoma. The dose of radiation therapy usually varies from 25 Gy to
50 Gy and is dependent on factors that include the histologic type of
lymphoma, the patient’s stage and overall condition, the goal of treatment
(curative or palliative), the proximity of sensitive surrounding organs, and
whether the patient is being treated with radiation therapy alone or in
combination with chemotherapy. Given the patterns of
disease presentations and relapse, treatment may need to include unusual sites
such as Waldeyer ring, epitrochlear, or mesenteric nodes. The
associated morbidity of the treatment must be considered carefully. The
majority of patients who receive radiation are usually treated on only one side
of the diaphragm. Localized presentations of extranodal NHL may be treated
with involved-field techniques with significant (>50%) success.

Even though standard treatment in patients with lymphomas can cure a significant fraction, numerous clinical trials that explore improvements in treatment are in progress. If possible, patients should be included in these studies. Standardized guidelines for response assessment have been suggested for use in clinical trials.[1]

Aggressive lymphomas are increasingly seen in human immunodeficiency virus (HIV)-positive patients; treatment
of these patients requires special consideration. (Refer to the PDQ summary on
AIDS-Related Lymphoma Treatment for more information.)

In addition to screening for HIV among patients with aggressive lymphomas, active hepatitis B or hepatitis C should be assessed prior to treatment with rituximab and/or chemotherapy.[2,3] Even patients with undetectable hepatitis B viral loads after remote past infection benefit from prophylaxis with entecavir in the context of rituximab therapy.[4] Similarly, prophylaxis for herpes zoster with acyclovir or valcyclovir and prophylaxis for pneumocystis with trimethoprim/sulfamethoxazole or dapsone are usually applied with rituximab with or without combination chemotherapy.

Several unusual presentations of lymphoma occur that often require somewhat modified approaches to staging and therapy. The reader is referred to reviews for a more detailed description of extranodal presentations in the gastrointestinal system,[5-13] thyroid,[14,15] spleen,[16] testis,[17-19] paranasal sinuses,[20-23] bone,[24,25] orbit,[26-30] and skin.[31-40]